Our staff looks forward to meeting you and discussing your child's pediatric care. We strive to keep our appointments on time, as scheduled. Prior to your appointment, we encourage you to fill out the patient forms below so you can accelerate your check-in process. Please download, print and complete the forms and bring them with you to your appointment. If you are unable to download our patient forms, then it is recommended that you arrive to your appointment between 15-30 minutes early so that you can have ample time to fill out the appropriate forms.
Consent to Obtain Prescription History
Caretaker Authorization for Medical Treatment
ImmTrac2 Minor Consent Form
Texas Immunization Registry
To easily keep up with your growing child’s vaccine records, we strongly urge all families to register their children under the Texas Immunization Registry, ImmTrac2. This vaccine registry serves as a secure system that combines your child’s records from various sources, and safely stores these documents all in one place.
To get started, your child must first be signed up for the Texas Immunization Registry, ImmTrac2. To register, please complete the minor consent form above and email back to us at [email protected] or print off and bring to their next appointment. An immunization registry account will immediately be created and your child. Consent is required one time and is valid until your child turns 18. Individuals 18 years and older must complete an adult consent form.
To have your child’s medical records sent to Village Pediatrics, please fill out the form “Authorization for Release To” below.
If you would like a copy of your child’s medical records or would like them sent to another medical office, please fill out the form “Authorization for Release From” below and return it to Village Pediatrics in-person, via fax or by emailing it to [email protected].
Records requests are processed through Vital Chart, a third-party. Vital Chart will provide you with access to your child’s records electronically through a portal where you can download or print these records. Please ensure your contact information is correct before submitting the form. Vital Chart charges a nominal fee for processing medical records. For questions or if it’s been more than 15 days since submitting your request and you haven’t received your child’s records, please contact Vital Chart at (972) 399-0941.
For help from a Village Pediatrics team member, please call (214) 473-2200 or text (469) 382-3796.
*Individual results are not guaranteed and may vary from person to person. Images may contain models.